This guideline addressed VTE prevention in hospitalized medical patients, outpatients with cancer, the chronically immobilized, long-distance travelers, and those with asymptomatic thrombophilia.
This guideline follows methods described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
For acutely ill hospitalized medical patients at increased risk of thrombosis, we recommend anticoagulant thromboprophylaxis with low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux (Grade 1B) and suggest against extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay (Grade 2B). For acutely ill hospitalized medical patients at low risk of thrombosis, we recommend against the use of pharmacologic prophylaxis or mechanical prophylaxis (Grade 1B). For acutely ill hospitalized medical patients at increased risk of thrombosis who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with graduated compression stockings (GCS) (Grade 2C) or intermittent pneumatic compression (IPC) (Grade 2C). For critically ill patients, we suggest using LMWH or LDUH thromboprophylaxis (Grade 2C). For critically ill patients who are bleeding or are at high risk for major bleeding, we suggest mechanical thromboprophylaxis with GCS and/or IPC at least until the bleeding risk decreases (Grade 2C). In outpatients with cancer who have no additional risk factors for VTE we suggest against routine prophylaxis with LMWH or LDUH (Grade 2B) and recommend against the prophylactic use of vitamin K antagonists (Grade 1B).
Decisions regarding prophylaxis in nonsurgical patients should be made after consideration of risk factors for both thrombosis and bleeding, clinical context, and patients’ values and preferences.From the Department of Medicine (Dr Kahn), McGill University, Montreal, QC, Canada; the Department of Medicine (Drs Lim and Cook), Division of Hematology and Thromboembolism (Dr Schulman), and the Department of Clinical Epidemiology and Biostatistics (Drs Akl and Cook), McMaster University, Hamilton, ON, Canada; the Department of Medicine (Dr Dunn), Mount Sinai School of Medicine, New York, NY; the Department of Medicine (Dr Cushman), University of Vermont and Fletcher Allen Health Care, Burlington, VT; the Department of Clinical Medicine (Dr Dentali), University of Insubria, Varese, Italy; the Department of Medicine (Dr Akl), University at Buffalo, Buffalo, NY; the Division of Pulmonary and Critical Care Medicine (Dr Balekian), Keck School of Medicine, University of Southern California, Los Angeles, CA; the Huntington Beach Internal Medicine Group (Dr Klein), Newport Beach, CA; the Department of Pulmonary and Critical Care Medicine (Dr Klein), University of California Irvine School of Medicine, Orange, CA; the Hoag Memorial Hospital Presbyterian (Dr Le), Newport Beach, CA; the Pulmonary Division (Dr Le), Fountain Valley Regional Hospital, Fountain Valley, CA; and the Division of Preventive Medicine and the Knowledge and Evaluation Research Unit (Dr Murad), Mayo Clinic, Rochester, MN.
Correspondence to: M. Hassan Murad, MD, MPH, 200 First St SW, Rochester, MN 55905; e-mail: Murad.Mohammad@mayo.edu
Author contributions: As Topic Editor, Dr Murad oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.Dr Murad: contributed as Topic Editor.
Dr Kahn: contributed as Deputy Editor.
Dr Lim: contributed as a panelist.
Dr Dunn: contributed as a panelist.
Dr Cushman: contributed as a panelist.
Dr Dentali: contributed as a panelist.
Dr Akl: contributed as a panelist.
Dr Cook: contributed as a panelist.
Dr Balekian: contributed as a resource consultant.
Dr Klein: contributed as a frontline clinician.
Dr Le: contributed as a frontline clinician.
Dr Schulman: contributed as a panelist.
Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related to each individual recommendation made in this article. A grid of these disclosures is available online at http://chestjournal.chestpubs.org/content/141/2_suppl/e195S/suppl/DC1. In summary, the authors have reported to CHEST the following conflicts of interest: Dr Kahn has received peer-reviewed and investigator-initiated industry research funding for projects related to venous thrombosis and postthrombotic syndrome prevention and treatment. She has received honoraria for industry-sponsored talks pertaining to venous thrombosis. Dr Balekian received industry research support and served as a consultant in areas relating to venous thrombosis. Dr Cook has received donated study drug (dalteparin) from Pfizer for a Canadian government-funded trial of thromboprophylaxis in the ICU. Dr Cushman is the mentor on a mentored research grant from the Hemophilia and Thrombosis Research Society that is studying risk factors for venous thrombosis among medical inpatients, 2009-2011. No specific dollar amount goes toward her salary. Dr Akl is a prominent contributor to the GRADE Working Group. Dr Murad is a member of the GRADE Working Group. Drs Lim, Dunn, Dentali, Klein, Le, and Schulman have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.
Endorsements: This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society of Thrombosis and Hematosis.
Additional information: The supplemental Tables can be found in the Online Data Supplement at http://chestjournal.chestpubs.org/content/141/2_suppl/e195S/suppl/DC1.Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants were also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).